A nurse manager is reviewing a group of incident reports as part of a quality improvement initiative.

Exhibits

For each incident report, click to specify if the findings in the incident report indicate a near miss or an adverse event. There must be at least 1 selection in every row. There does not need to be a selection in every column.

A. Change IV solution bags every 36 hr: Changing IV solution bags every 36 hours may not align with evidence-based practices aimed at promoting cost-effective care. Instead, guidelines typically recommend changing them based on clinical need or specific protocols, which can help reduce waste and costs.

B. Avoid the delegation of hygiene care to assistive personnel (AP): Delegating hygiene care to assistive personnel is essential for effective team functioning and cost-effective care. Preventing delegation can lead to increased workloads for nursing staff, which may not be the most efficient use of resources.

C. Wear sterile gloves when removing urinary retention catheters: Wearing sterile gloves when removing urinary retention catheters is not necessary; clean gloves are sufficient for this procedure. Promoting correct practices that align with guidelines can help reduce costs associated with unnecessary supplies.

D. Educate staff about the correct use of personal protective equipment (PPE) for isolation precautions: Educating staff on the correct use of PPE is vital for preventing infection, reducing the spread of illness, and minimizing healthcare costs associated with complications. Proper training ensures that resources are used effectively, promoting both safety and cost-effective care.

Near miss:

• Incident Report 1: The nurse identified the client's allergy before administering azithromycin, preventing an adverse reaction. Holding the medication and notifying the provider ensured patient safety, making this a near miss rather than an adverse event.

Adverse Event:

• Incident Report 2: The client did not receive prescribed prophylactic antibiotics during labor, leading to neonatal sepsis. The lack of antibiotic administration increased the risk of serious complications, making this an adverse event with potential long-term consequences.

• Incident Report 3: A tenfold dosing error led to the administration of 60 units instead of 6 units of insulin, resulting in severe hypoglycemia and unresponsiveness. This critical medication error placed the client at significant risk for neurological damage or death, classifying it as an adverse event.

• Incident Report 4: A critically low platelet value was reported but not communicated to the provider, delaying intervention and leading to a coma. The failure to act on critical lab results contributed to a preventable deterioration in the client’s condition, making this an adverse event.

• Incident Report 5: Despite being identified as a fall risk, the client sustained a fall due to a malfunctioning call bell, leading to an injury. The failure to address the defective equipment compromised patient safety, making this an adverse event that could have been prevented.